OMB#0581-0189

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TEXAS VALLEY CITRUS COMMITTEE						No. __________________
901 Business Park Drive 
Suite 500
Mission, Texas  78572
Telephone: (956) 581-2190
Fax: (956) 584-0300

ORANGE AND GRAPEFRUIT DIVERSION REPORT

Issued under authority of Certificate of Privilege No. ______________		Date _______________________

Receiver:	
		Name of approved processor, charitable organization, relief, or otherwise

Address 	
Truck Lic.: _____	Trailer Lic.: ______	Inspection Cert. No.: ______	R.R. Car Initial & No.: ______

Quantity (Total Lbs. Net Actual or Estimate)
_______Grapefruit

________Oranges

Charity/Relief
Grapefruit
Containers

Total Lbs. Net


Oranges
Containers

Total Lbs. Net

Otherwise Diverted
Grapefruit
Containers

Total Lbs. Net


Oranges
Containers

Total Lbs. Net


The undersigned certifies that these oranges or grapefruit are diverted from fresh fruit channels in accordance with the regulations of the Texas Valley Citrus Committee (the “Committee”).

______________________________________		_______________________________________
Handler							Authorized Representative

TO BE FILLED IN BY RECEIVER:
Quantity received: ________________ Grapefruit		_________________ Oranges

The undersigned acknowledges receipt of the above fruit, and certifies that it will be diverted from fresh channels in accordance with the Committee regulations.

________________________________________		______________________________
Receiving Organization						Authorized Representative

The making of any false statements or representation in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of Title 18, section 1001 of the United States Code, which provides for a penalty of a fine of $10,000, or imprisonment of not more than five years, or both.

INSTRUCTIONS:  Mail the white (original) copy of this form to the Committee.  The canary (duplicate) and pink (triplicate) copies must be given to the party receiving the fruit.  Upon arrival at the destination, the party transporting the fruit must give both copies to the party actually receiving the fruit, whereupon said party must insert the net weight of the fruit received, sign, and promptly mail the canary copy to the Committee.  The pink copy may be retained by the manufacturer for filing purposes.  The gold (quadruplicate) copy may be retained for filing purposes by the Handler authorizing movement of this fruit.


NOTE:  According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0581-0189.  The time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs).  Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).

To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).  USDA is an equal opportunity provider and employer.